Asian Spine J Search


Asian Spine J > Volume 18(3); 2024 > Article
Pholsawatchai, Manakul, Lertcheewanan, Siribumrungwoung, Suntharapa, and Arunakul: Response to the Letter to the Editor: Comparison of efficacy between transforaminal epidural steroid injection technique without contrast versus with contrast in lumbar radiculopathy: a prospective longitudinal cohort study
Dear Editor,
Thank you for your insightful comments and for the opportunity to address the concerns raised regarding our study titled “Comparison of efficacy between transforaminal epidural steroid injection technique without contrast versus with contrast in lumbar radiculopathy: a prospective longitudinal cohort study” [1].

Detection of intravascular penetration

We appreciate your concern about the potential for intravascular penetration during epidural steroid injections. In our study, we employed the drawback technique to minimize this risk. While it is true that real-time fluoroscopy with contrast can enhance the detection of intravascular injections, our approach prioritized a balance between efficacy and practicality. According to Visnjevac et al. [2] in 2015, the use of digital subtraction angiography versus real-time fluoroscopy for detecting intravascular penetration, mention about the anatomic location and the type of needle differed among the four analyzed reports. Three of four studies reported the use of Quincke needles, but varied in gauge. The fourth study reported gauge, but not type of needle. Our study uses the clear anatomical location and 23G Quincke spinal needle (Becton Dickinson S.A., Madrid, Spain) in every patient. Also, Ko et al. [3] in 2022 report that identifying needle-induced pain during the non-contrast transforaminal epidural steroid injection procedure, when it matches the patient’s chief complaint of radiating pain, is sufficient for accurate nerve root localization. Without greater complication. The drawback technique, combined with careful patient selection and experienced clinicians, helped mitigate the risk of vascular penetration. Additionally, we monitored patients closely for any signs of complications post-procedure, and no adverse events were observed.

Use of particulate steroids

Our decision to use particulate steroids was based on existing literature that supports their efficacy in certain clinical scenarios. While we acknowledge the potential risks associated with particulate steroids, we ensured that all patients were thoroughly evaluated for contraindications. Delaney and MacMahon [4] in 2023 highlighted that while particulate steroids carry risks, they can be used safely in selected cases with appropriate precautions. The specific particulate steroid used in our study, triamcinolone acetonide, has a well-documented safety profile when administered correctly. We believe that the benefits in terms of pain relief and functional improvement justified its use in our patient population. Our methodology was consistent with current recommendations to minimize risks associated with particulate steroid use.

Reported complication rates

The absence of reported complications in our study reflects our rigorous monitoring and follow-up protocols. All patients were observed for a minimum of 4 hours post-procedure and followed up at 2 weeks and 2 months. Any adverse events, regardless of severity, were documented. Sencan et al. [5] in 2022 reported that immediate adverse events in lumbar interventional pain procedures were generally low, which aligns with our findings. We believe that our comprehensive approach to patient care contributed to the lower complication rates observed. Please note that in our study, which has 118 samples may not large enough to reveal the relatively low complication rate, further research is suggest.
We appreciate the opportunity to clarify these points and hope that our responses address your concerns adequately. Thank you for your interest in our study and for contributing to the ongoing discourse in this important area of clinical practice.


Conflict of Interest

No potential conflict of interest relevant to this article was reported.

Author Contributions

All authors provided the same amount of effort for the preparation of this commentary.


1. Pholsawatchai W, Manakul P, Lertcheewanan W, Siribumrungwoung K, Suntharapa T, Arunakul R. Comparison of efficacy between transforaminal epidural steroid injection technique without contrast versus with contrast in lumbar radiculopathy: a prospective longitudinal cohort study. Asian Spine J 2023;17:1108–16.
crossref pmid pmc pdf
2. Visnjevac O, Kim P, Farid-Davari S, Johnson P, Nader ND. Digital subtraction angiography versus real-time fluoroscopy for detection of intravascular penetration prior to epidural steroid injections: meta-analysis of prospective studies. Pain Physician 2015;18:29–36.
3. Ko S, Nam J, Lee J. Usefulness of the additional contrast agents to identify offending nerve root in selective nerve root block. Medicine (Baltimore) 2022;101:e25131.
crossref pmid pmc
4. Delaney FT, MacMahon PJ. An update on epidural steroid injections: is there still a role for particulate corticosteroids? Skeletal Radiol 2023;52:1863–71.
crossref pmid pdf
5. Sencan S, Sacaklidir R, Gunduz OH. The immediate adverse events of lumbar interventional pain procedures in 4,209 patients: an observational clinical study. Pain Med 2022;23:76–80.
crossref pmid pdf


Browse all articles >

Editorial Office
Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine
88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea
Tel: +82-2-3010-3530    Fax: +82-2-3010-8555    E-mail:                
Korean Society of Spine Surgery
27, Dongguk-ro, Ilsandong-gu, Goyang-si 10326, Korea
Tel: +82-31-966-3413    Fax: +82-2-831-3414    E-mail:                

Copyright © 2024 by Korean Society of Spine Surgery.

Developed in M2PI

Close layer
prev next